IFP Summary of Benefits 2024 - Medical and Specialty

The following documents are effective January 1, 2024.

For prior year documents, please see 2023 Medical Summary of Benefits.

To help your clients understand their plan benefits, we have provided documents in a simplified format which will either be the Summary of Benefits (SOB) or a Benefit Summary only for specific Specialty plans. Your client will also be able to access their SOB as part of their Evidence of Coverage (EOC) or policy on blueshieldca.com/policies along with their Summary of Benefits and Coverage (SBC).

When sharing the SOB and/or Benefit Summary with your client, you must also provide the Legal Disclosure document applicable to the medical, dental or vision plan.

Trio HMO plans

Click here for disclosure.

Trio HMO Plans Summary of Benefits
Blue Shield Platinum 90 Trio HMO English (PDF, 2 MB)
Spanish (PDF, 2 MB)
Blue Shield Gold 80 Trio HMO English (PDF, 2 MB)
Spanish (PDF, 2 MB)
Blue Shield Silver 70 Trio HMO English (PDF, 2 MB)
Spanish (PDF, 2 MB)
Silver 70 Off Exchange Trio HMO English (PDF, 2 MB)
Spanish (PDF, 2 MB)
Blue Shield Bronze 7500 Trio HMO English (PDF, 2 MB)
Spanish (PDF, 2 MB)

We offer three Silver Trio HMO cost-sharing reduction plans through Covered California for clients whose income is between 138% to 250% of the federal poverty level (FPL). These plans are available only through Covered California.

Trio HMO Cost-Sharing Reduction Plans Summary of Benefits
Blue Shield Silver 73 Trio HMO English (PDF, 2 MB)
Spanish (PDF, 2 MB)
Blue Shield Silver 87 Trio HMO English (PDF, 2 MB)
Spanish (PDF, 2 MB)
Blue Shield Silver 94 Trio HMO English (PDF, 2 MB)
Spanish (PDF, 2 MB)

PPO plans

Click here for disclosure.

PPO Plans Summary of Benefits
Blue Shield Platinum 90 PPO English (PDF, 2 MB)
Spanish (PDF, 2 MB)
Blue Shield Gold 80 PPO English (PDF, 2 MB)
Spanish (PDF, 2 MB)
Blue Shield Silver 70 PPO English (PDF, 2 MB)
Spanish (PDF, 2 MB)
Silver 70 Off Exchange PPO English (PDF, 2 MB)
Spanish (PDF, 2 MB)
Silver 1750 PPO English (PDF, 2 MB)
Spanish (PDF, 2 MB)
Silver 2600 HDHP PPO English (PDF, 2 MB)
Spanish (PDF, 2 MB)
Blue Shield Bronze 60 PPO English (PDF, 2 MB)
Spanish (PDF, 2 MB)
Blue Shield Bronze 60 HDHP PPO English (PDF, 2 MB)
Spanish (PDF, 2 MB)
Blue Shield Minimum Coverage PPO English (PDF, 2 MB)
Spanish (PDF, 2 MB)

We offer three Silver PPO cost-sharing reduction plans through Covered California for clients whose income is between 138% to 250% of the federal poverty level (FPL). These plans are available only through Covered California.

PPO Cost-Sharing Reduction Plans Summary of Benefits
Blue Shield Silver 73 PPO English (PDF, 2 MB)
Spanish (PDF, 2 MB)
Blue Shield Silver 87 PPO English (PDF, 2 MB)
Spanish (PDF, 2 MB)
Blue Shield Silver 94 PPO English (PDF, 2 MB)
Spanish (PDF, 2 MB)

Alaska Native and American Indian Plans

We offer American Indian and Alaska Native plans for each metal level that are available only to eligible American Indians and Alaska Natives through Covered California. These plans differ from the standard metal level plans in that they allow American Indian and Alaska Native members to access covered services from American Indian and Alaskan Native providers for no out-of-pocket costs. In addition to the Alaska Native and American Indian versions of the standard metal level plans, we offer a $0 cost share PPO plan to American Indian and Alaska Native members who qualify based on household income. Members can choose to access covered services through a Blue Shield participating provider or non-network provider for an out-of-pocket cost.

Click here for disclosure.

Alaska Native and American Indian Trio HMO Plans Summary of Benefits
Blue Shield Platinum 90 Trio HMO AI-AN English (PDF, 2 MB)
Spanish (PDF, 2 MB)
Blue Shield Gold 80 Trio HMO AI-AN English (PDF, 2 MB)
Spanish (PDF, 2 MB)
Blue Shield Silver 70 Trio HMO AI-AN English (PDF, 2 MB)
Spanish (PDF, 2 MB)
Blue Shield $0 Cost Share Trio HMO AI-AN English (PDF, 2 MB)
Spanish (PDF, 2 MB)
Alaska Native and American Indian PPO Plans Summary of Benefits
Blue Shield Platinum 90 PPO AI-AN English (PDF, 2 MB)
Spanish (PDF, 2 MB)
Blue Shield Gold 80 PPO AI-AN English (PDF, 2 MB)
Spanish (PDF, 2 MB)
Blue Shield Silver 70 PPO AI-AN English (PDF, 2 MB)
Spanish (PDF, 2 MB)
Blue Shield Bronze 60 PPO AI-AN English (PDF, 2 MB)
Spanish (PDF, 2 MB)
Blue Shield Bronze 60 HDHP PPO AI-AN English (PDF, 2 MB)
Spanish (PDF, 2 MB)
Blue Shield $0 Cost Share PPO AI-AN English (PDF, 2 MB)
Spanish (PDF, 2 MB)

Specialty Plans

Summary of Benefits are available for dental plans while Benefit Summaries are available for vision plans. Dental and vision plans sold through Blue Shield can be purchased with a Blue Shield medical plan or as stand-alone policies. Family Dental Plans are sold only through Covered California and can only be purchased when enrolling in a medical plan sold through Covered California.

Dental Plans Underwritten by DMHC

Click here for disclosure.

Plan Name Summary of Benefits
Dental PPO English (PDF, 1.2 MB)
Spanish (PDF, 1.2 MB)
Dental PPO 1500 English (PDF, 2 MB)
Spanish (PDF, 2 MB)
Enhanced Dental PPO 50/2000 English (PDF, 2 MB)
Spanish (PDF, 2 MB)
Enhanced Dental PPO 50/2000 Lifetime Ortho 1500 English (PDF, 2 MB)
Spanish (PDF, 2 MB)
Dental HMO English (PDF, 2 MB)
Spanish (PDF, 2 MB)
Dental Standard HMO English (PDF, 2 MB)
Spanish (PDF, 2 MB)

Dental Plans Underwritten by CDI

Click here for disclosure.

Plan Name Benefit Summary
Specialty Duo dental (sold with Duo vision below) English (PDF, 2 MB)
Spanish (PDF, 2 MB)

Family Dental Plans (sold exclusively through Covered California) - Underwritten by DMHC

Click here for disclosure.

Plan Name Summary of Benefits
Family Dental PPO English (PDF, 2 MB)
Spanish (PDF, 2 MB)
Family Dental HMO English (PDF, 2 MB)
Spanish (PDF, 2 MB)

Vision Plans Underwritten by CDI

Click here for disclosure.

Plan Name Benefit Summary
Ultimate Vision 15/25/120 English (PDF, 2 MB)
Spanish (PDF, 2MB)
Ultimate Vision 15/25/150 English (PDF, 2 MB)
Spanish (PDF, 2MB)
Specialty Duo vision (sold with Duo dental above) English (PDF, 2 MB)
Spanish (PDF, 2MB)

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